Naomi Kakushima

Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type)

Background:  Although the strip biopsy method and aspiration method are popular endoscopic mucosal resection techniques for its convenience and reliability, they have limitations in resectable tumor size and location. Endoscopic submucosal dissection techniques using the diathermic needle knife or the insulated‐tip diathermic knife have been introduced to overcome this disadvantage, but they have high risks for bleeding and perforation. Therefore, we have developed a new endoscopic submucosal dissection technique using the tip of an electrosurgical snare (thin type) and assessed its efficacy.

Endoscopic submucosal dissection for the reliable en bloc resection of colorectal mucosal tumors

Scheduled piecemeal resection has been actively conducted for granular type laterally spreading tumor (LST‐G) in Japan, as long as a definite preoperative diagnosis is made. However, en bloc resection is desirable for depressed lesions (e.g. IIc lesion) as well as non‐granular type laterally spreading tumor (LST‐NG) since they have considerable high risk for submucoasl invasion and require precise histopathological evaluation. Endoscopic submucosal dissection (ESD) has been developed for the en bloc resection of mucosal tumors of gastrointestinal tract and widely applied especially in gastric lesions. Although the large intestine involves structural and technical difficulties, we conducted en bloc resection by ESD while exercising sorts of ingenuity for preparation; endoscopes, instruments, local injections, and others. ESD is a reliable technique that allows en bloc resection of gastrointestinal mucosal lesions, and even has a splendid possibility for the treatment of early stage colorectal cancer.

Endoscopic submucosal dissection using flexknife.

Although the standard treatment for early-stage gastrointestinal tumors is still surgical resection, endoscopic resection has been accepted for some of these lesions, especially in Japan. However, the indication was limited until recently to achieve en bloc resection and prevent local recurrence. To overcome the disadvantage of endoscopic resection with conventional endoscopic mucosal resection (EMR), several investigators, including us, have developed a new endoscopic resection technique: endoscopic submucosal dissection (ESD). ESD is a remarkable technique that enables to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. Nowadays, several knives are available for ESD, such as the needle knife, insulation-tipped (IT) knife, Hookknife, triangle-tipped (TT) knife, and Flexknife. Each of them has some merits and demerits, and the ways to use the knives are different. We summarize here how to use the Flexknife, which we made ourselves in cooperation with the Olympus Company, and how we use the technique in our hospital.

Helicobacter pylori status and the extent of gastric atrophy do not affect ulcer healing after endoscopic submucosal dissection

Background:  Eradication therapy for Helicobacter pylori is effective in preventing peptic ulcer recurrence, but its efficacy in ulcer healing is still controversial. The effect of H. pylori on artificial ulcers after endoscopic resection is not known. The purpose of the present study was therefore to evaluate the influence of H. pylori infection on ulcer healing after endoscopic submucosal dissection (ESD).

Technical feasibility of endoscopic submucosal dissection for gastric neoplasms in the elderly Japanese population

Background and Aim:  Endoscopic submucosal dissection (ESD) is gaining acceptance among endoscopists for its efficacy, especially in Japan. Elderly patients often have operative risk due to comorbid diseases, and the feasibility of this treatment for such patients should be investigated. The aim of this study is to evaluate the efficacy and safety of ESD in elderly patients.

Characteristics of autoimmune pancreatitis based on serum IgG4 level.

BACKGROUND Autoimmune pancreatitis is categorized as an IgG4-related autoimmune disease, mostly associated with serological alterations, however characteristics of autoimmune pancreatitis based on serum markers have not been fully evaluated. METHODS We evaluated demographics, symptoms, imaging and therapeutic outcome in 27 cases of autoimmune pancreatitis stratified by serum IgG4 level. RESULTS Twenty patients (74%) had elevated serum IgG4 and 7 (26%) had normal IgG4 levels. Compared to patients with normal serum IgG4 levels, patients with elevated IgG4 had higher incidence of jaundice at onset (14.3% vs. 80%, respectively; P=0.002), more frequent diffuse pancreatic enlargement at imaging (14.3% vs. 60%, respectively; P=0.04), significantly higher 18F-2-fluoro-2-deoxy-d-glucose uptake of pancreatic lesions (SUV max: 4.0 vs. 5.7, respectively; P=0.02), more frequent extrapancreatic lesions (42.9% vs. 85%, respectively; P=0.03). Response to steroids was recognized regardless of serum IgG4 level, however maintenance therapy was required more frequently amongst patients with elevated compared to normal IgG4 (85.7% vs. 33.3%, respectively; P=0.04). CONCLUSIONS Clinical features of autoimmune pancreatitis are different based on level of serum IgG4. Further studies are needed to clarify if normal serum IgG4 cases are a precursor of active type 1 or type 2 autoimmune pancreatitis.

Discrepancies in histologic diagnoses of early gastric cancer between biopsy and endoscopic mucosal resection specimens

BackgroundA preoperative histologic diagnosis of neoplasia is a requirement for endoscopic resection (ER). However, discrepancies may occur between histologic diagnoses based on biopsy specimens versus ER specimens. The aim of this study was to assess the rate of discrepancy between histologic diagnoses from biopsy specimens and ER specimens.MethodsA total of 1705 gastric lesions, from 1419 patients with a biopsy diagnosis of neoplasia, were treated by ER from September 2002 to December 2008. We compared the histologic diagnosis from the biopsy sample and the final diagnosis from the ER specimen to assess the discrepancy rate. Clinicopathological characteristics of the lesions that were related to the histologic discrepancies were also studied.ResultsAn ER diagnosis of gastric cancer was made in 49% (118/241) of lesions diagnosed as borderline lesions from biopsy specimens; this included adenomas and lesions difficult to diagnose as regenerative or neoplastic. The size, existence of a depressed area, and ulceration findings were significant factors observed in these lesions. An ER diagnosis of differentiated type cancer was obtained for 17% (12/63) of lesions diagnosed as undifferentiated type cancer from the biopsy specimens; for these lesions, the color and a mixed histology were significant factors related to the histologic discrepancies.ConclusionA biopsy diagnosis of borderline lesions or undifferentiated type cancer is more likely to disagree with the diagnosis from ER specimens. Endoscopic characteristics should be considered together with the biopsy diagnosis to determine the treatment strategy for these lesions.

Multi‐center survey regarding the management of anticoagulation and antiplatelet therapy for endoscopic procedures in Japan

Background:  A guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures has been established from Japan Gastroenterological Endoscopy Society in 2005. However, it is unknown whether consensus on the management of these conditions is obtained among endoscopists in daily practice owing to the guideline.

Endoscopic diagnosis of superficial non‐ampullary duodenal epithelial tumors in Japan: Multicenter case series

To verify the current status in Japan on endoscopic diagnosis of superficial non‐ampullary duodenal epithelial tumors (SNADET) by a multicenter case series through a questionnaire survey.

Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training.

BACKGROUND AND AIMS The technical difficulties inherent in endoscopic submucosal dissection (ESD) for colorectal neoplasms may result in the failure of en bloc resection or perforation. The aim of this retrospective study was to assess the predictors of en bloc resection failure or perforation by using preoperatively available factors. METHODS Between September 2002 and March 2013, 716 colorectal ESDs in 673 consecutive patients were performed at a tertiary cancer center. Patient characteristics, tumor location, tumor type, colonoscopy-related factors, and endoscopist experience were assessed based on a prospectively recorded institutional ESD database. Logistic regression analysis was performed to identify predictors of failure of en bloc resection or perforations, with subgroup analyses of ESDs performed by endoscopists less experienced in colorectal ESD (<40 cases) and for colonic lesions only. RESULTS On multivariate analysis, independent predictors of failure of en bloc resection or perforations were the presence of fold convergence (odds ratio [OR] 4.4; 95% confidence interval [95% CI], 1.9-9.9), protruding type (OR 3.6; 95% CI, 1.8-7.1), poor endoscope operability (OR 3.5; 95% CI, 1.8-6.9), right-sided colonic lesions (OR 3.0; 95% CI, 1.5-6.3 vs rectal lesions), left-sided colonic lesions (OR 3.2; 95% CI, 1.7-6.3, vs rectal lesions), the presence of an underlying semilunar fold (OR 2.1; 95% CI, 1.3-3.6), and a less-experienced endoscopist (OR 2.1; 95% CI, 1.3-3.6). Among less-experienced endoscopists, colonic lesions were independent predictors (right-sided colonic lesions 8.1; 95% CI, 2.9-25.1; left-sided colonic lesions 8.1; 95% CI, 2.5-28.3 vs rectal lesions). For colonic lesions, the presence of fold convergence (OR 3.7; 95% CI, 1.6-8.6), poor endoscope operability (OR 3.6; 95% CI, 1.8-7.2), a less-experienced endoscopist (OR 3.0; 95% CI, 1.7-1.8), and the presence of an underlying semilunar fold (OR 2.7; 95% CI, 1.5-4.7) were identified predictors. CONCLUSION This study successfully identified predictors of en bloc resection failure or perforation. Understanding these indicators could help to accurately stratify lesions according to technical difficulty and to appropriately select endoscopists.